Diaphragmatic hernia (DH) is a critical condition in veterinary medicine defined by the disruption of the diaphragmatic continuity, allowing abdominal viscera to protrude into the thoracic cavity (Gaikwad et al., 2024). While congenital defects occur, the condition is most frequently acquired following blunt force trauma, such as falls from heights or automobile accidents (Pereira et al., 2023). The pathophysiology involves the loss of negative intrathoracic pressure and mechanical compression of lungs, leading to respiratory compromise and potentially, cardiovascular instability (Hyun, 2004).
       
The clinical presentation of DH can vary significantly based on the volume of herniated viscera and the duration of the condition. Common signs include dyspnea, tachypnea and exercise intolerance (Pereira et al., 2023). However, diagnosis can present a significant challenge when clinical signs mimic primary cardiac disease (Kumar et al., 2005; Shao et al., 2024).
       
Surgical repair (herniorrhaphy) is the definitive treatment for DH (Gaikwad et al., 2024). Conventional inhalational anaesthesia depends on efficient pulmonary ventilation for uptake and elimination of anaesthetic gases. In diaphragmatic hernia patients, compromised lung expansion and reduced functional residual capacity may result in unpredictable anaesthetic delivery and increased anaesthetic risk. The objective of this study is to describe the successful diagnostic approach and surgical management of a traumatic diaphragmatic hernia in a young dog using TIVA protocol.

The clinical study and surgical management were carried out during the year 2025 at the Department of Veterinary Surgery and Radiology, College of Veterinary Science, PVNRTVU, Rajendranagar, Hyderabad, Telangana, India.
 
Patient selection
 
The study involved a 3.5-year-old intact male Labrador Retriever weighing 25 kg with a normal body condition score. The patient was presented to the clinic with a history of trauma (fall from height) occurring two weeks prior, exhibiting clinical signs of post-prandial and post-defecation syncope.
 
Diagnostic protocol
 
Baseline physiological parameters were assessed and standard presurgical hematological and biochemical panels (Complete blood count, liver function tests and kidney function tests) were performed to evaluate systemic health status.
       
Radiographic evaluation consisted of plain thoracic radiographs in left and right lateral views. To confirm the diagnosis, a positive contrast radiographic study was conducted. A dose of 30 ml of Barium Sulphate suspension (Microbar®) was administered undiluted per os. A confirmatory contrast radiograph was also scheduled for the immediate post-operative period to validate the repositioning of the visceral organs.
 
Anaesthetic protocol
 
The patient was prepared for aseptic surgery. Pre-anaesthetic medication was administered using a cocktail of xylazine (1 mg/kg) and ketamine (10 mg/kg). Approximately 75% of the calculated cocktail dose was administered to achieve sedation. Following sedation, anaesthesia was induced using propofol at a dose rate of 4 mg/kg intravenously. The patient was intubated with a cuffed endotracheal tube to ensure a patent airway.
       
Maintenance of anaesthesia was achieved via total intravenous anaesthesia (TIVA). This involved the administration of intermittent boluses of the Xylazine-Ketamine cocktail and Propofol, titrated to effect to maintain surgical depth and cardiovascular stability. Additionally, local analgesia was provided by infiltrating Lignocaine along the proposed incision line.
 
Surgical procedure
 
The animal was restrained in dorsal recumbency. A cranial ventral midline abdominal incision was performed to access the abdominal cavity. Upon visualization of the diaphragmatic defect, the herniated viscera were gently retracted back into the abdominal cavity.
       
The diaphragmatic herniorrhaphy was performed using a two-material technique: the rent was initially apposed using no. 2 Polyglactin (Vicryl) absorbable sutures in a simple interrupted pattern, followed by a layer of no. 2 Polyamide non-absorbable suture in a simple continuous pattern to ensure tensile strength.
       
Following completion of the diaphragmatic repair, negative intrathoracic pressure was reestablished by gentle evacuation of air from the thoracic cavity using thoracocentesis with a sterile syringe and three-way stopcock assembly while providing positive pressure ventilation prior to final abdominal closure.
       
Following the repair of the diaphragm, the abdominal wall was closed in layers. The muscle layer was sutured using no.2 polyglactin 910 (Vicryl) in a simple interrupted pattern. The subcutaneous tissue was closed using 2-0 polyglactin 910 (Vicryl) in a simple continuous pattern. Finally, the skin incision was closed using non-absorbable 2-0 polyamide sutures in cross-mattress pattern.
 
Post-operative management
 
Post-operative care included fluid therapy using ringer’s lactate (RL) for three days. Systemic antibiotic coverage was provided with Inj. Ceftriaxone-tazobactam (Intacef Tazo®) at 25 mg/kg IV. Analgesia was managed using Inj. Meloxicam (Melonex®) at 0.2 mg/kg. Supportive therapy included the administration of Inj. Ranitidine (Rantac®), Inj. Chlorpheniramine maleate and vitamin B-complex injection (Tribivet®) intramuscularly.
       
The owner was advised to feed a soft diet in small, frequent quantities to prevent gastric overload. Skin sutures were removed on the 14^th post-operative day following uneventful healing.

Diagnostic findings
 
The diagnostic workup confirmed a traumatic diaphragmatic hernia (DH) and ruled out primary cardiac disease as the cause of the syncopal episodes. Table 1 summarizes the key pre-surgical diagnostic findings. The patient exhibited lateral recumbency immediately following a post-prandial syncopal episode (Fig 1).




       
Plain thoracic radiographs revealed elevated VHS, dorsally displaced trachea and gas-filled intestinal loops within the thoracic cavity suggestive of diaphragmatic hernia (Fig 2). Contrast radiography further confirmed displacement of intestinal loops into the thoracic cavity (Fig 3).










 
Surgical and anaesthetic outcomes
 
Intraoperative findings
 
The abdominal viscera were gently retracted from the thoracic cavity and the diaphragmatic defect was clearly visualized and repaired by herniorrhaphy. The intraoperative sequence of diaphragmatic herniorrhaphy performed through a ventral midline approach is illustrated in Fig 7.


 
Anaesthetic management
 
TIVA using xylazine-ketamine cocktail and propofol, titrated to effect, successfully maintained surgical depth and cardiovascular stability throughout the high-risk procedure.
 
Herniorrhaphy detail
 
The repair was achieved using a two-material technique: an inner layer of no. 2 polyglactin (Vicryl) absorbable in a simple interrupted pattern and an outer layer of no. 2 polyamide non-absorbable suture in a simple continuous pattern to ensure tensile strength.

Post-operative outcome and recovery
 
The patient showed complete resolution of respiratory distress and syncopal episodes following recovery. Post-operative monitoring and contrast radiography confirmed restoration of normal physiological status and successful repositioning of abdominal viscera. Post-operative thoraco-abdominal radiographs demonstrated restoration of normal thoracic and abdominal anatomy (Fig 8). Post-operative barium contrast radiography confirmed complete retention of abdominal viscera within the abdominal cavity without recurrence of herniation (Fig 9).




 
Long-term follow-up
 
The dog resumed normal exercise tolerance and feeding habits without recurrence of syncope. The patient showed normal stance, alertness and clinical recovery at the five-month follow-up examination (Fig 10).


       
The diagnosis and management of traumatic diaphragmatic hernia (DH) in this Labrador Retriever highlight several critical clinical considerations, particularly regarding atypical presentations and anaesthetic choices for high-risk patients. While dyspnea is the predominant sign in acute cases, chronic or delayed presentations often exhibit more complex gastrointestinal or systemic symptoms (Pereira et al., 2023; Shao et al., 2024).
 
Pathophysiology of syncope in DH
 
Post-prandial gastric distension and straining during defecation likely increased intrathoracic compression by displaced abdominal viscera, resulting in transient reduction in venous return and cardiac output leading to syncopal episodes (Shao et al., 2024).
 
Differential diagnosis
 
The patient’s clinical signs initially mimicked primary cardiac disease. The use of 2D-echocardiography was essential to rule out cardiac anomalies before confirming the hernia via contrast radiography. As noted in previous studies, radiographic signs such as the loss of the diaphragmatic line and masking of the cardiac silhouette are reliable indicators of hernia (Hyun, 2004). In this case, 2D-echocardiography was crucial to rule out congenital anomalies like Peritoneopericardial Diaphragmatic Hernia (PPDH) or cardiomyopathy before surgery (Hennet and Field, 2024). The use of a positive contrast study (barium) definitively confirmed the displacement of the intestines, a method supported by literature when plain films are ambiguous (Hyun, 2004; Kumar et al., 2005).

Anaesthetic and surgical management
 
Diaphragmatic herniorrhaphy is considered anaesthetically challenging because respiratory compromise and altered thoracic mechanics may increase perioperative risk (Yadav et al., 2024). TIVA using Propofol and Xylazine-Ketamine provided stable anaesthetic depth and cardiovascular control throughout the procedure. In diaphragmatic hernia patients, compromised pulmonary function may make inhalational anaesthesia less predictable due to impaired gaseous exchange. Therefore, TIVA was preferred to achieve reliable anaesthetic maintenance independent of pulmonary anaesthetic uptake.
 
Surgical repair
 
Surgical repair is the only definitive treatment for restoring cardiopulmonary function (Suryawanshi et al., 2023, Gaikwad et al., 2024). Diaphragmatic herniorrhaphy is commonly performed in dorsal recumbency under general anaesthesia (Sangwan and Kumar, 2026). A ventral midline approach was used, which allows for excellent visualization and reduction of abdominal organs (Shao et al., 2024). The two-material suture technique provided adequate apposition and tensile strength for diaphragmatic repair.
 
Comparisons and implications
 
Most traumatic diaphragmatic hernia cases present with acute respiratory distress; however, chronic cases may exhibit gastrointestinal or syncopal manifestations. This case highlights syncope as a potential clinical sign of diaphragmatic hernia associated with increased intra-abdominal pressure.

This case highlights the importance of considering diaphragmatic hernia as a differential diagnosis in dogs presenting with respiratory distress and recurrent syncope following feeding or defecation. Comprehensive radiographic evaluation and timely surgical intervention resulted in successful restoration of cardiopulmonary function. TIVA provided safe anaesthetic management in this patient with compromised pulmonary capacity.

The authors declare that there is no conflict of interest regarding the publication of this manuscript.